Provider Demographics
NPI:1336225481
Name:BOUCHER, KARI (MD)
Entity Type:Individual
Prefix:
First Name:KARI
Middle Name:
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 EVERGREEN DR
Mailing Address - Street 2:SUITE 20
Mailing Address - City:GLEN MILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19342-1032
Mailing Address - Country:US
Mailing Address - Phone:484-785-3376
Mailing Address - Fax:610-358-6913
Practice Address - Street 1:500 EVERGREEN DR
Practice Address - Street 2:SUITE 20
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342-1032
Practice Address - Country:US
Practice Address - Phone:484-785-3376
Practice Address - Fax:610-358-6913
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD417529207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1438394OtherBLUE SHIELD
PA2122596000OtherIBC
PAH53790Medicare UPIN
PA053847FB7Medicare PIN
PAP00042717Medicare PIN